Sickle Cell Pain Management

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Pain Management in Sickle Cell DiseaseAllan
Platt, PA-CThe Georgia Comprehensive Sickle Cell
Centerat Grady Health System
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What is Sickle Cell Disease?

• Genetic disorder of hemoglobin
• Complications due to hemolysis, vessel occlusions
  from misshapen RBCs adhesion, infections, organ
  failure, and pain episodes
• Gene is common in Africa, Middle East,
  Mediterranean Basin, and India
• Detection, education, preventive health care can
  save lives

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Why Start a Center?

• Prior to 1984 all patients seen in the ER
• Erratic care, no continuity, poor pain management
• Long waits for care
• Many hospitalizations, Many ER visits, Many
  patient complaints
• No comprehensive care
• High Cost, High Acuity

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Objectives of the Sickle Cell Center

• 1. 24 Hour Urgent Care
• 2. Comprehensive Primary Care
• 3. Multidisciplinary Team
• 4. Tertiary Care
• 5. Education
• 6. Research
• 7. Disease Management
• 8. Worldwide Resource

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Multidisciplinary Team

• PA/NP/MD as Consistent Providers
• Newborn Screening Coordinator
• RN/LPN as Care Managers, Teachers
• SW / CNS-Psych as Support Team
• Multimedia Vocational Rehabilitation
• Techs/Clerical - Patient Advocates
• Consultants - Eye, Nutrition, Audiology, Child
  Psychiatry, Physical Therapy

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24 Hour Urgent Care

• Over 15 years old, non-pregnant, non-trauma
• MD-PA, RN, Clinic Assistant Model
• Problem Specific Clinical Guidelines Developed
  over 15 years
• Aggressive Pain and Fluid Management
• 8 Hours of Treatment until Admit Decision
• Online Information - Instant Medical Records

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Treatment of Pain Episodes

• Step wise - multimodal approach with parenteral
  agents and pain assessment
• Evaluate to determine cause of pain
• Bed rest, quiet environment
• Hydration IV D5W or oral
• Analgesics
• NSAIAs - Ketorolac
• Agonist Narcotics - Morphine
• Agonist-Antagonist - Nalbuphine
• Adjuvants - Hydroxyzine

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Guidelines - Online

• World Wide Web Site - The Sickle Cell Information
  Center
• http//www.emory.edu/PEDS/SICKLE
• Information for providers, patients, teachers,
  employers, administrators
• 2 online books
• 19,000 hits a day
• 10 email questions a day

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10 year data 1991 - 2001

• 20,968 pain episodes
• 1,076 patients over 15 years old
• Average age 36.8 years old
• oldest patient 82
• 51 male, 49 female visits
• Pain Assessment using VAS
• Admission if
• Complication Fever, infiltrate, hct
• Return within 48 hours
• Pain not manageable after 8 hours

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8 Hour Treatment - 20,968 episodes over 10 years
20 Admitted, 80 went home 3988 Admissions 52
Left AMA 92 Critical Care
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Pain Score - Patients going home
Pain-in 8.2 Pain-out 4.1
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Pain Score - Patients Admitted
Pain-in 8.8 Pain-out 7.7
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Active Patients - Admissions

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Pain Crisis - Admissions

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Pain Crisis Episodes and Admissions per Active
Adult
Pain Episodes per active adult
3.1 Pain 0.5 Admit
Case Management

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Impact of Frequent Visitors vs. Active Adults
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Analgesics Used in 20,968 Pain Episodes in 1,076
Adults
Demerol
Nubain was used in 57 of pain episodes
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THE FUTURE

• Teach Patients and Parents
• Early Prevention
• Early Treatment
• Early Screening
• Better Education
• Better Pain Management
• Prevent Complications
• A cure for all